Sunday, 15 September 2013

Liverpool Care Pathway - The Rationing Of Available Resources

When they began to count the cost, they had to cost the account. The beginning was the end...

The rationing of available resources and the beginnings of the Communitarian perspective

The 1970’s saw NHS reorganisation. Recommendations from the management consultants, McKinsey's, and Brunel University were sought.
Both bodies added greatly to the richness of the jargon used in the NHS. 'The exclusion of representatives,' said the Lancet, 'is defended on the ground that management should not be confused with the community's reaction to management - administering the health service is too serious a matter to be shared with the citizenry.'NHS History
1974 shared one characteristic with 1948: the outcome was the best available compromise. Many groups had to be placated by the addition of another tier, committee or special interest group. Attempts were made to be fair to the staff who were having to apply, if not for their own jobs, for something like them. MOsH who, in 1948, had stayed in their posts now had to compete to be area medical officers. The number of top posts was smaller, many moved to new areas and much talent was lost. There were personal tragedies and at least one suicide. There was similar turbulence among nursing and administrative officers.

Some were converts; one quoted Peter Drucker as saying that the NHS was grotesquely over-administered and dangerously under-managed. Most, including clinicians, probably agreed with a writer in the Lancet who said
We are at last coming in sight of the Great Day when, according to the prophets, a second coming of the NHS is going to cause the rooting out of all that is bad in the present system and lead us into some therapeutic Heaven, where all will be perfection, peace and light. But the whole business is being viewed with much less than fervent optimism by many of us who actually come into contact with patients - the 'grass roots' of the service. And let's face it, grass roots puts us in our place, as low down as you can get. From our lowly viewpoint the NHS looks like a particularly nervous colony of ants which has just had a particularly large garden fork shoved in and stirred around. Individuals race hither and thither, carrying little schemes with them and giving them to others, who carry them a little further and pass them on in their turn. Of course the trouble is we don't understand. We are unable to share the enthusiasm of our administrative colleagues as, with the schoolboy eagerness of modern Druids waiting for the midsummer sun to rise at Stonehenge, they prepare for the New Day. 
Florence Nightingale said that hospital management was important and difficult to learn, requiring experience. 267 Senior staff whose length of service had given them pride and loyalty to their institution now either left or became disillusioned. Expertise in the management of outbreaks of infectious disease was lost, as over 100 MOsH left the NHS. Few of the new managers were committed to the hospitals, regarding their jobs as stepping stones to something better. They were so busy with paper work and meetings that they were never seen about the place. Their future lay at the upper levels of an over-heavy bureaucracy and they deserted their posts in droves, leaving huge general hospitals to be run by a succession of juniors, to the dismay of medical staff.
Nurses marched on Hyde Park and Clive Jenkins, Manager's Union leader of ASTMS, was stirring it up. Jenkins will always be remembered for his famous title piece in the London Evening Standard that proclaimed: “You Won’t Know What to Do with Yourselves” (inspired by the growth of an increasingly automated society, the completion of the Post Office Tower in 1965, Harold Wilson’s famous 'White Heat' speech, itself a reference, perhaps, to Lenin's famous 'Electricity' comment, paralleling the imperative of technological advance for economic survival, and that computers would one day be talking to computers down the telephone line). All that was coming, of course, but we’re still working long hours and more are being demanded of us.
In Newcastle the medical staff decided to integrate geriatrics with other general medical services. pooling beds as part of multi-consultant teams, all taking part in acute medical emergency work. In Oldham the unit was also an intrinsic part of the DGH, and provided total medical care with virtually no waiting list. Turnover more than kept pace with demand. When the new Northwick Park Hospital opened, the geriatrician, Malcolm Hodkinson, decided that from the outset his department would have neither a waiting list nor a system of pre-admission assessment. The emphasis would be on active treatment and early discharge. Those who could not be discharged, roughly half, were transferred to two smaller hospitals so that the department followed a scheme of progressive patient care. The morale of the staff improved and there was less tendency to treat geriatrics as 'the poor relation' of medicine.
The warning shots had already been fired, however -
Commons — July 11, 1967
            Mr Patrick Gordon Walker 
One of the results of debates such as this—we have had a number on this subject—is that it has become generally understood, and is almost a truism, how rapidly the elderly population is increasing and will continue to increase. It is probable that by the 1980s there will be about 10 million people over retirement age, and between now and the 1980s—this is a very serious problem for those who have to plan the development of the social services—the proportion of the dependent population—those under school-leaving age, on the one hand, and those over retirement age, on the other—will be rising much more rapidly than the working population, which has to produce the wealth from which we pay for social security.
The stresses were straining the system. There were demands for redistribution of resources. The formation of the Resource Allocation Working Party (RAWP) was announced in July 1975

1976 saw publication of the Priorities Document, the so-called RAWP Report.

The Priorities document

1976 was the high point for RHA's (Regional Health Authorities) and Corporate Planning. Barbara Castle published her 'Priorities for Health and Personal Social Services in England' which expounded the view that an economic wake-up call would be placing financial restrictions on limited available resources and that serious choices had to be made.
The BMJ referred it as a document of despair. At a time of economic recession current expenditure would continue to increase in real terms but the capital programme would be halved. It was increasingly clear, said the journal, that the NHS could not balance its books and stood no chance of doing so. 
Right at the close of the second decade, had come publication of Sans Everything by Barbara Robb on behalf of AEGIS (Aid for the Elderly in Government Institutions). The publication came like a nuclear blast, the fall out from which made itself felt well into the next.
The regional hospital boards (RHBs) were asked to investigate. The reports were heavily edited before publication and the tenor was to dismiss the accusations as inaccurate, misinterpretation or isolated aberrations of individual staff some of whom subsequently retired. Kenneth Robinson told Parliament he deeply regretted the anxiety caused to patients, relatives and hospital staff by allegations now authoritatively discredited. The BMJ was pleased that staff and hospitals had been exonerated. The Nursing Times described Sans everything as an exercise in mud-slinging; the Minister, reacting to public concern, had made careful enquiries and allegations of cruelty by nurses were not proven. Some thought his response smelt of a white-wash. 
Both BMJ and Nursing Times, in denial, came out in support of their own.

The Whistle-blowers had been given encouragement. Also in that final year -
a nursing assistant at Ely Hospital Cardiff made specific allegations to the News of the World about the treatment of patients and pilfering by staff. They were forwarded to the Minister. Kenneth Robinson, though Labour, commissioned an enquiry under the chairmanship of Geoffrey Howe QC, a budding Conservative politician, thereby ensuring cross-party support. Howe and his committee worked hard. Richard Crossman was Minister by the time the report was published. It appeared in full only after some argument but Crossman came out strongly in favour of publishing the entire reportThe allegations had been confirmed and the most serious accusations were directed at an inert nursing administration that had victimised staff who complained.  Staff who, for years, had either lived with the system or got out, now sometimes spoke up, ignoring the possibility of retribution. After the publication of the Ely report in March 1969, regions were asked to examine their own services, and increased allocations of capital and revenue were made to services for the mentally handicapped. 
The crucial development of this, the third, decade of the NHS was the recognition that most people admitted to medical wards were the elderly.

Should general physicians accept patients, however old, as just 'patients'? Should there be a defined age at which everyone was admitted under the care of a geriatrician, allocating patients on the basis of age rather than clinical requirements?

The 20th anniversary of the NHS saw the provider merge with the financer and the Ministry of Health combined with the Ministry of Social Security to form the DHSS (Department of Health and Social Security). The accountants began to account for themselves.

In 1970, the King's Fund established a working party on the application of economic principles to health service management. 'Accounting for Health' (King's Fund Report) was published in 1973.

When the patient is not a patient but singled out as a class, a group or a category, that class, that group or category will stand out like a sore thumb in the costings for the accounts if it is placing a particular and immoderate or inordinate demand upon the available resources.

Furthermore, if that class or group or category is no longer making contributions toward funding those available resources but actually depleting those available resources further by actually demanding pensions, incremented year on year, and receiving other benefits besides, the accountant attempting to balance the account may look to make cost savings in that particular class, group or category in order to balance the books in the absence of no other method of funding it.

One, two, how many Neasdens have there been, overlooked, unreported and unnoted...?

These hidden agendas are become a programme, overt in design, cunningly benign... but deadly!

The programme to limit life

Today's NHS, in calm and stoic acceptance that all cannot be saved or may not be worth saving - after all, what are a few extra weeks, months, and lacking quality at that? - has made that class, that group or category, long ago identified, its focus and the EoLC Strategy is well established.

It has all been about changing minds. Patients, already groomed with the mindset to die, have 'just in case' boxes sitting in readiness in their homes.

They have been diagnosed with dying, so it doesn't really matter because they're going to die, right...?

This document alerts the NHS in England and Wales to review and improve measures for safer practice in prescribing, storing, administering and identifying high dosemorphine and diamorphine injections. It advises all NHS organisations to put measures in place to protect patients from simple but potentially fatal mistakes.
There have been a number of reports of deaths and harm due to the administration of high dose (30mg or greater) diamorphine or morphine injections to patients who had not previously received doses of opiates.
The main risks have been identified as: lookalike / similar packaging for different strengths of diamorphine and morphine ampoules; poorly differentiated outer cartons and ampoules; higher and lower strength ampoules of diamorphine and morphine stored together in clinical areas in both primary and secondary care; and insufficient therapeutic training and understanding by healthcare staff of the risks and precautions when prescribing, dispensing and administering higher doses of these medicines.
The document sets out background information, the actions required, and how to implement these whilst ensuring urgent access to palliative care drugs.
It is accompanied by a patient briefing in English and Welsh for patients being given morphine or diamorphine for the first time.
Although the deadline for actions has passed, this guidance remains best practice. It should be followed to prevent future patient safety incidents.
Ensuring safer practice with high dose ampoules of diamorphine and morphine - Safer Pratice Notice
Ensuring safer practice with high dose ampoules of diamorphine and 
morphine - Safer Pratice Notice - 321 KB0295 - Ensuring safer practice with high dose ampoules of diamorphine and morphine - Safer Pratice Notice - 2006-05-25 - V1
Ensuring safer practice with morphine and diamorphine injections - Patient Briefing
Ensuring safer practice with morphine and diamorphine injections - 
Patient Briefing - 26 KB0309A - Ensuring safer practice with morphine and diamorphine injections - Patient Briefing - 2006-05-25 - V1 - CY

Ensuring safer practice with morphine and diamorphine injections - Patient Briefing
Ensuring safer practice with morphine and diamorphine injections - Patient Briefing - 39 KB0309 - Ensuring safer practice with morphine and diamorphine injections - Patient Briefing - 2006-05-25 - V1

 The PDF. states for action to
Ensure that naloxone injection, an antidote to opiate-induced respiratory depression, is available in all clinical locations where diamorphine and morphine injections are stored or administered.
Not one of the LCP 'just in case' boxes deployed to Care Homes and for use in the patient's own homes, apparently, contains Naloxone (the antidote to respiratory depression advised in the Patient Safety Alert).

It is clearly the strategy of the EoLC Programme to limit life. Once on the Pathway, whichever pathway that is, there is no turning back; not if they can help it, there isn't.
The Iron Lady

The Pathway is not reversible.

To paraphrase the Iron Lady:
"The Pathway is not for turning!"
The document advises doing risk assessments.

The document makes recommendations and how to implement these "whilst ensuring urgent access to palliative care drugs".

These have gone unheard or unheeded.

Dr. Ellershaw...?

Dr. Bee Wee...?

The design is clear and plain, and they have actually achieved the impossible and made it desirable.

The Complete Lives System is on schedule.

This is the National Audit Office -
"So far the NHS is meeting the challenge of maintaining strong finances in a period of austerity. It is clear, however, that parts of the service are under strain. "For value for money to be delivered in future, two things are required: firstly, careful management of the risks created by transition to a new commissioning model; and, secondly a coherent and transparent financial support mechanism which outlines when trusts should be supported, or allowed to fail." - Amyas Morse, head of the National Audit Office, 5 July 2012

The headlined report, 'Securing the future financial sustainability of the NHS', maintains that the NHS delivered a £2.1 billion surplus in 2011-12 but that there is some 'financial distress' in NHS Trusts with some very large deficits.

On target, perhaps. Much has been achieved already, then.

There is still much more to achieve, however. The pensions black hole still gapes its maw ready to gulp down the careless or unwary economist and politician.

Further reading -
Excess Deaths 
Sans Everything

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